ES2716206T3 - Intraventricular enzyme distribution for lysosomal deposition diseases - Google Patents

Abstract

An acid sphingomyelinase for use in the prevention or treatment of Niemann-Pick A or B disease in a patient, wherein said prevention or treatment comprises intraventricular administration of acid sphingomyelinase to the patient's brain, in which the administration of A single dose of acid sphingomyelinase consumes more than five hours.

Description

DESCRIPTION

Intraventricular enzyme distribution for lysosomal deposition diseases.

Technical Field of the Invention

This invention relates to the area of lysosomal deposition diseases. In particular, it refers to the treatment and / or prevention of these diseases by enzyme replacement therapy.

Compendium of the invention

A group of metabolic disorders known as lysosomal deposition diseases (EDL) includes more than forty genetic disorders, many of which involve genetic defects in several lysosomal hydrolases. Representative lysosomal deposition diseases and associated defective enzymes are listed in Table 1.

Table 1

Lysosomal deposition disease Defective enzyme Aspartylglucosaminuria Aspartylglucosaminidase

Fabry Alpha-galactosidase A

Childhood Batten Disease * (CNL1) Palmitoyl Protein Thioesterase Classic Late Childhood Batten Disease * (CNL2) Tripeptidyl Peptidase

Juvenile Batten disease * (CNL3) Batten lysosomal transmembrane protein, other forms * (CNL4-CNL8) Multiple gene products

Cystinosis Cysteine transporter

Farber Acid Ceramidase

Fucosidosis Alpha-L-Fucosidase acid Galactosidosialidosis Protective protein / cathepsin A

Gaucher types 1, 2 * and 3 * Beta-glucosidase acid, or

G.sub.M1 gangliosidosis * Acid beta-galactosidase

Hunter * Iduronate-2-sulfatase

Hurler-Scheie * Alfa-L-iduronidase

Krabbe * Galactocerebrosidase

alpha-Mannosidosis * Acid alpha-Mannosidase

beta-Mannosidosis * Acid beta-Mannosidase

Maroteaux-Lamy Arilsulfatasa B

Metachromatic leukodystrophy * Arilsulfatase A

Morquio A N-acetylgalactosamine-6-sulfate Morquio B Acid beta-galactosidase

Mucolipidosis II / III * N-acetylglucosamine-1-Niemann-Pick A *, B acid sphingomyelinase

Niemann-Pick C * NPC-1

Pompe * acid alpha-glucosidase

Sandhoff * Beta-Hexosaminidase B

Sanfilippo A * Heparan N-sulfatase

Sanfilippo B * Alfa-N-acetylglucosaminidase

Sanfilippo C * Acetyl-CoA: alpha-glucosaminide

Sanfilippo D * N-acetylglucosamine-6-sulfate

Schindler's disease * Alpha-N-acetylgalactosaminidase

Schindler-Kanzaki Alfa-N-acetylgalactosaminidase

Sialidosis Alfa-Neuramidase

Sly * Beta-glucuronidase

Tay-Sachs * Beta-Hexosaminidase A

Wolman * Acid Lipase

* CNS involvement

The distinctive feature of EDL is the abnormal accumulation of metabolites in lysosomes that leads to the formation of large numbers of distended lysosomes in the pericarion. A major challenge to treat EDL (unlike to treat an organ-specific enzyme disease, eg, a liver-specific enzyme disease) is the need to reverse the pathology by lysosomal deposition in multiple separate tissues. Some EDLs can be treated effectively by intravenous infusion of the lost enzyme, known as enzyme replacement therapy (TSE). For example, type 1 Gaucher patients have only visceral disease and respond favorably to TSE with recombinant glucocerebrosidase (Cerezyme ™, Genzyme Corp.). However, patients with metabolic disease that affects the CNS (eg, Gaucher disease type 2 or 3) only partially respond to intravenous TSE because the replacement enzyme is prevented from entering the brain by the blood-brain barrier (BHE) ). In addition, attempts to introduce a replacement enzyme into the brain by direct injection have been limited in part due to enzymatic cytotoxicity at high local concentrations and parenchymal diffusion rates in the brain have been limited (Partridge, Peptide Drug Deliver to the Brain, Raven Press, 1991).

An exemplary EDL is Niemann-Pick type A disease (NPA). According to the UniProtKB / Swiss-Prot P17405 entry, defects in the SMPD1 gene, located on chromosome 11, (11p15.4-p15.1), are the cause of Niemann-Pick type A (NPA) disease, also denominated as the classic infantile form of the disease. Niemann-Pick disease is a clinically heterogeneous and recessive disorder. It is caused by the accumulation of sphingomyelin and other metabolically related lipids in lysosomes, resulting in neurodegeneration that begins from early life. Patients may show xanthomas, pigmentation, hepatosplenomegaly, lymphadenopathy and mental retardation. Niemann-Pick disease occurs more frequently among individuals of Asquenazi Jewish descent than in the general population. NPA is characterized by a very early beginning in childhood and a rapidly progressive trajectory that leads to death in three years. The acid sphingomyelinase enzyme (EMA) that is defective in NPA converts sphingomyelin to ceramide. EMA also has phospholipase C activities towards 1,2-diacylglycerolphosphocholine and 1,2-diacylglycerolphosphoglycerol. The enzyme converts

Sphingomyelin H ₂ O → N-acylphingosine choline phosphate.

In accordance with the present description, lysosomal deposition diseases such as any of the diseases identified in Table 1 above, eg, Niemann-Pick type A or B disease, are treated and / or prevented using intraventricular distribution to the brain of the enzyme that is etiologically deficient in the disease. Administration can be done slowly to achieve maximum effect. The effects are seen on both sides of the blood brain barrier, making this a useful means of distribution for lysosomal deposition diseases that affect the brain and / or visceral organs. In a first aspect, the present description therefore provides a method of treatment or prevention of a disease by lysosomal deposition in the patient, whose disease is caused by an enzymatic deficiency, the method comprising administering the enzyme to the patient by means of distribution intraventricular to the brain. In a related aspect, the present description provides the use of an enzyme for the manufacture of a medicament for the treatment or prevention of a disease by lysosomal deposition in a patient, whose disease is caused by a deficiency of the enzyme in the patient, in which the treatment or prevention includes the intraventricular administration of the enzyme to the brain. Enzyme deficiency may be caused by eg a defect in the expression of the enzyme or by a mutation in the enzyme that leads to a reduced level of activity (eg, the enzyme being inactive) or an increased rate of clearance / breakdown of the enzyme in vivo. The deficiency can lead to an accumulation of an enzyme substrate and administration of the enzyme can lead to a reduction in the level of the substrate in the brain. Lysosomal deposition disease can be any of the diseases identified in Table 1 above. The enzyme can be a lysosomal hydrolase.

According to an example of the present description, a patient with Niemann-Pick A or B disease is treated. An acid sphingomyelinase is administered to the patient by intraventricular distribution to the brain in an amount sufficient to reduce sphingomyelin levels in said brain.

Another aspect of the present description is a kit to treat or prevent a disease by lysosomal deposition in a patient, whose disease is caused by an enzymatic deficiency. The kit comprises the enzyme that is deficient, and a catheter and / or pump for the distribution of the enzyme to one or more ventricles in the brain. The catheter and / or pump may be specifically designed and / or adapted for intraventricular distribution. According to one example, the present description provides a kit for treating a patient with Niemann-Pick A or B disease. The kit comprises an acid sphingomyelinase and a catheter for the distribution of said acid sphingomyelinase to the patient's brain ventricles.

Still another aspect of the present description is a kit for treating a patient with Niemann-Pick A or B disease. The kit comprises an acid sphingomyelinase and a pump for the distribution of said acid sphingomyelinase to the patient's brain ventricles.

According to the present description, a patient who has a lysosomal deposition disease that is caused by an enzymatic deficiency that leads to the accumulation of the enzyme substrate can be treated. Such diseases include Gaucher disease, MPS I and II disease, Pompe disease, and Batten disease (CLN2), among others. The defective enzyme in the particular disease is administered to the patient through intraventricular distribution to the brain. It can be administered to the lateral ventricles and / or the fourth ventricle. The rate of administration of the enzyme according to the present description is such that the administration of a single dose may be as a bolus or it may take approximately 1-5 minutes, approximately 5-10 minutes, approximately 10-30 minutes, approximately 30 -60 minutes, approximately 1-4 hours, or consume more than four, five, six, seven or eight hours. Substrate levels in said brain can therefore be reduced. The administration of a single dose may take more than 1 minute, more than 2 minutes, more than 5 minutes, more than 10 minutes, more than 20 minutes, more than 30 minutes, more than 1 hour, more than 2 hours or more than Three hours.

These and other examples of the present description that will be apparent to those skilled in the art after reading the report provide the technique with methods and kits for the treatment and / or prevention of diseases by lysosomal deposition, in particular those that involve both pathologies of the CNS as visceral.

Based on the present description, the present invention provides an acid sphingomyelinase for use in the prevention or treatment of Niemann-Pick A or B disease in a patient, wherein said prevention or treatment comprises intraventricular administration of sphingomyelinase. acid to the patient's brain, in which the administration of a single dose of acid sphingomyelinase consumes more than five hours.

Additional aspects and embodiments of the invention are presented in the appended claims.

Brief description of the drawings

FIG. 1 shows a diagram of sections of the brain that were analyzed for sphingomyelin. S1 is in the front of the brain and S5 is in the back of the brain.

FIG. 2 shows that the intraventricular administration of EMAhr reduces the levels of MS in the ASMKO mouse brain.

FIG. 3 shows the intraventricular administration of EMAhr reduces the levels of MS in the liver, spleen and lung ASMKO.

FIG. 4 shows the staining of EMAh in the brain after intraventricular infusion.

FIG. 5 shows that the intraventricular infusion of EMAhr over a period of 6 h reduces the levels of MS in ^the AsMKO ^mouse brain.

FIG. 6 shows that the intraventricular infusion of EMAhr over a period of 6 h reduces the levels of MS in the liver, serum and lung ASMKO.

FIG. 7 shows documented variants of EMAh and their relationship with disease or enzymatic activity.

FIG. 8 shows a cross-sectional view of the brain with the ventricles indicated.

FIGS. 9A and 9B show the side and top views, respectively, of the ventricles.

FIG. 10 shows the injection in the lateral ventricles.

Detailed description of the invention

The practice of the present description, which includes the present invention, will employ, unless otherwise indicated, conventional techniques of immunology, molecular biology, microbiology, cell biology and recombinant DNA, which is in the characteristics of the technique. See, eg, Sambrook, Fritsch and Maniatis, Molecular Cloning: A laboratory manual, 2nd edition (1989); Current protocols in molecular biology (F.M. Ausubel, et al., Eds., (1987)); the Methods in enzymology series (Academic Press, Inc.): PCR 2: A practical approach (M.J. MacPherson, B.D. Hames and G.R. Taylor eds. (1995)); Harlow and Lane, eds. (1988) Antibodies, a laboratory manual, and Animal cell culture (R.I. Freshney, ed. (1987)).

As used in the specification and claims, the singular forms "a", "a" and "the" include plural references unless the context clearly dictates otherwise. For example, the term "one cell" includes a plurality of cells, including mixtures thereof.

As used herein, the term "comprising" is intended to indicate that the compositions and methods include the elements listed, but do not exclude others. "Which consists essentially of" when used to define compositions and methods, will mean that they exclude other elements of any essential importance to the combination. Accordingly, a composition consisting essentially of the elements as defined herein would not exclude trace contaminants from the isolation and purification method and pharmaceutically acceptable carriers, such as phosphate buffered saline, preservatives and the like. "Consisting of" shall mean that it excludes more than trace elements of other ingredients and that it excludes essential method steps to administer the compositions or medicaments in accordance with the present description. The embodiments defined by each of the transition terms are within the scope of this invention. All numerical designations, eg, pH, temperature, time, concentration and molecular weight, including intervals, are approximations that are varied (+) or (-) by increments of 0.1. It is to be understood, although it is not always explicitly stated that all numerical designations are preceded by the term "approximately." It is also to be understood, although not always explicitly stated, that the reagents described herein are merely exemplary and that equivalents of those known in the art can also be used.

The terms "therapeutic", "therapeutically effective amount" and their like refer to that amount of a substance, eg, enzyme or protein, which results in the prevention or delay of the onset, or improvement, of one or more symptoms of a disease in a subject, or an achievement of a desired biological outcome, such as the correction of neuropathology. The term "therapeutic correction" refers to the degree of correction that results in the prevention or delay of the onset, or improvement, of one or more symptoms in a subject. The effective amount can be determined by known empirical methods.

A "composition" or "medicament" is intended to include a combination of an active agent, eg, an enzyme, and a vehicle or other material, eg, a compound or composition, which is inert (for example, a detectable agent or label) or active, such as an adjuvant, diluent, binder, stabilizer, buffer, salt, lipophilic solvent, preservative, adjuvant or the like, or a mixture of two or more of these substances. The vehicles are preferably pharmaceutically acceptable. They may include pharmaceutical excipients and additives, proteins, peptides, amino acids, lipids and carbohydrates (eg, sugars, which include monosaccharides, di-, tri-, tetra- and oligosaccharides; derived sugars such as alditols, aldonic acids, esterified sugars and the like; and polysaccharides or sugar polymers), which may be present individually or in combination, comprising alone or in combination 1-99.99% by weight or volume. Exemplary protein excipients include serum albumin such as human serum albumin (ASH), recombinant human albumin (AHr), gelatin, casein and the like. Representative amino acid / antibody components, which can also function in a buffering capacity, include alanine, glycine, arginine, betaine, histidine, glutamic acid, aspartic acid, cysteine, lysine, leucine, isoleucine, valine, methionine, phenylalanine, aspartama and Similar. Carbohydrate excipients are also provided within the scope of the present description, which includes the present invention, the examples of which include but are not limited to monosaccharides such as fructose, maltose, galactose, glucose, D-mannose, sorbose and the like; disaccharides, such as lactose, sucrose, trehalose, cellobiose and the like; polysaccharides, such as raffinose, melezitose, maltodextrins, dextrans, starches and the like; and alditols, such as mannitol, xylitol, lactitol, xylitol, sorbitol (glucitol) and myoinositol.

The term "vehicle" also includes a buffer or a pH adjusting agent or a composition containing it; Typically, the buffer is a salt prepared from an organic acid or base. Representative buffers include organic acid salts such as salts of citric acid, ascorbic acid, gluconic acid, carbonic acid, tartaric acid, succinic acid, acetic acid or phthalic acid, Tris buffers, tromethamine hydrochloride or phosphate. Additional carriers include polymeric excipients / additives such as polyvinylpyrrolidones, phyols (a polymeric sugar), dextrates (eg, cyclodextrins, such as 2-hydroxypropyl quadratura-cyclodextrin), polyethylene glycols, flavoring agents, antimicrobial agents, sweeteners, antioxidants, antistatic agents, surfactants (eg, polysorbates such as "TWEEN 20" and "TWEEN 80"), lipids (eg. , phospholipids, fatty acids), steroids (eg, cholesterol) and chelating agents (eg, EDTA).

As used herein, the term "pharmaceutically acceptable carrier" includes any of the standard pharmaceutical carriers, such as a phosphate buffered saline solution, water and emulsions, such as oil / water or water / oil emulsion, and various types of wetting agents. Compositions and medicaments that are manufactured and / or used in accordance with the present description and that include the particular enzyme whose deficiency is to be corrected may include stabilizers and preservatives and any of the vehicles noted above with the additional condition that they are acceptable for Use in vivo. For examples of vehicles, stabilizers and adjuvants, see Martin Remington's Pharm. Sci. 15th Ed. (Mack Publ. Co., Easton (1975) and Williams & Williams (1995), and in the "Physician's Desk Reference", 52nd Ed., Medical Economics, Montvale, NJ (1998).

A "subject", "individual" or "patient" is used interchangeably herein, which refers to a vertebrate, preferably a mammal, more preferably a human. Mammals include, but are not limited to, mice, rats, monkeys, humans, farm animals, sports animals and pets.

As used herein, the term "modular" means varying the amount or intensity of an effect or result, eg, improve, increase, decrease or decrease.

As used herein the term "improve" is synonymous with "relieve" and means reduce or lighten. For example, one can improve the symptoms of a disease or disorder by making it more tolerable.

For the identification of structures in the human brain, see, e.g., The Human Brain: Surface, Three-Dimensional Sectional Anatomy With MRI, and Blood Supply, 2nd ed., Eds. Deuteron et al., Springer Vela, 1999; Atlas of the Human Brain, eds. Mai et al., Academic Press; 1997; and Co-Planar Stereotaxic Atlas of the Human Brain: 3-Dimensional Proportional System: An Approach to Cerebral Imaging, eds. Tamarack et al., Thyme Medical Pub., 1988. For the identification of structures in the mouse brain, see, eg, The Mouse Brain in Stereotaxic Coordinates, 2nd ed., Academic Press, 2000.

The inventors have discovered that intraventricular distribution to the brain of lysosomal hydrolase enzymes to patients that are deficient in enzymes, leads to an improved metabolic state of both the brain and the affected visceral organs (not CNS). This is particularly true when the distribution speed is slow, relative to the distribution of a bolus. Lysosomal deposition diseases caused by a deficiency in a particular enzyme, such as the diseases identified in Table 1 above, can therefore be treated or prevented by intraventricular administration of the respective enzyme. An enzyme particularly useful for treating Niemann-Pick A or B is acid sphingomyelinase (EMA), such as that shown in SEQ ID NO: 1.1 An enzyme particularly useful for treating Gaucher disease is glucocerebrosidase. An enzyme particularly useful for treating MPS I disease is alpha-L-iduronidase. An enzyme particularly useful for treating MPS II disease is iduronate-2-sulfatase. An enzyme particularly useful for treating Pompe disease, or type II glycogen deposition disease (GSDII), also called acid maltose deficiency (AMD), is acidic alphaglucosidase. An enzyme particularly useful for treating classical late childhood Batten disease (CLN2) tripeptidyl peptidase. Enzymes that are used and / or administered in accordance with the present disclosure may be recombinant forms of enzymes that are produced using methods that are well known in the art. In one example, the enzyme is a recombinant human enzyme.

The administration of lysosomal enzymes, and more particularly lysosomal hydrolase enzymes, to patients that are deficient in enzymes can be performed in any one or more of the brain ventricles, which are filled with cerebrospinal fluid (FCE). The FCE is a clear fluid that fills the ventricles, is present in the subarachnoid space, and surrounds the brain and spinal cord. FCE is produced by the choroid plexuses and through the suppuration or transmission of tissue fluid through the brain in the ventricles. The choroid plexus is a structure that covers the floor of the lateral ventricle and the roof of the third and fourth ventricles. Certain studies have indicated that these structures are capable of producing 400-600 ccs of fluid per day consistent with an amount to fill the spaces of the central nervous system four times a day. In adults, the volume of this fluid has been calculated to be 125 to 150 ml (4-5 ounces). The FCE is in training, circulation and continuous absorption. Certain studies have indicated that approximately 430 to 450 ml (almost 2 cups) of FCE can occur every day. Certain calculations estimate that production equals approximately 0.35 ml per minute in adults and 0.15 per minute in children. The choroid plexuses of the lateral ventricles produce the majority of FCE. It flows through the forages of Monro to the third ventricle where it is added to the production of the third ventricle and continues down through the aqueduct of Silvio to the fourth ventricle. The fourth ventricle adds more FCE; The fluid then travels to the subarachnoid space through the forages of Magendie and Luschka. It then circulates along the base of the brain, down around the spinal cord and up over the cerebral hemispheres. The FCE empties into the blood through arachnoid villi and vascular sinuses. 1 _{Residues 1-46 constitute the signal sequence that is cleaved after secretion.}

intracranial, thus distributing the enzymes that are infused in the ventricles not only to the brain but also to the visceral organs that are known to be affected in the EDL.

Although a particular amino acid sequence is shown in SEQ ID NO: 1, variants of that sequence that retain activity can also be used, eg, normal variants in the human population. Typically these normal variants differ in only one or two residues from the sequence shown in SEQ ID NO: 1. The variants of SEQ ID NO: 1 to be used in accordance with the present description, including the present invention, whether they occur naturally or not, should be at least 95%, 96%, 97%, 98% or 99% identical to SEQ ID NO: 1. Variants of other enzymes can be used in accordance with the present description. However, regardless of the enzyme used, variants that are associated with the disease or reduced activity would not be used. Typically the mature form of the enzyme will be distributed. In the case of SEQ ID NO: 1, the mature form will begin with residue 47 as shown in SEQ ID NO: 1. Variants that are associated with the disease are shown in FIG. 7. Similarly, the normal variants in the human population of said EDL enzymes such as glucocerebrosidase, alpha-L-iduronidase, iduronate-2-sulfatase, acid alpha-glucosidase and tripeptidyl peptidase which can also be used when retaining enzyme activity .

The kits according to the present description are separate component assemblies. Although they can be packaged in a single container, they can be sub-packaged separately. Even a single container can be divided into compartments. Typically an instruction set will accompany the kit and provide instructions for the distribution of enzymes, eg, lysosomal hydrolase enzymes, intraventricularly. The instructions may be in print, electronically, such as an instructional video or DVD, or a compact disc, on a floppy disk, on the Internet with an address provided on the package, or a combination of these media. Other components, such as diluents, buffers, solvents, tape, screws and maintenance tools may be provided in addition to the enzyme, one or more cannulas or catheters, and / or a pump.

The populations treated by the methods of the present description include, but are not limited to, patients who have, or are at risk of developing, a neurometabolic disorder, eg, an EDL, such as the diseases listed in the Table. 1, particularly if said disease affects the CNS and visceral organs. In an illustrative example, the disease is Niemann-Pick type A disease.

An EMA or other lysosomal hydrolase enzyme can be incorporated into a pharmaceutical composition useful for treating, eg, inhibiting, attenuating, preventing or improving, a condition characterized by an insufficient level of a lysosomal hydrolase activity. The pharmaceutical composition will be administered to a subject suffering from a lysosomal hydrolase deficiency or someone who is at risk of developing said deficiency. The compositions would contain a therapeutic or prophylactic amount of the EMA or other lysosomal hydrolase enzyme, in a pharmaceutically acceptable carrier. The pharmaceutical carrier can be any compatible, non-toxic substance suitable for distributing the polypeptides to the patient. Sterile water, alcohol, fats and waxes can be used as the vehicle. Pharmaceutically acceptable adjuvants, buffering agents, dispersing agents and the like, can also be incorporated into pharmaceutical compositions. The vehicle can be combined with the EMA or other lysosomal hydrolase enzyme in any form suitable for administration by intraventricular injection or infusion (the form of which is also possibly suitable for intravenous or intrathecal administration) or otherwise. Suitable carriers include, for example, physiological saline, bacteriostatic water, Cremophor ELTM (BASF, Parsippany, NJ) or phosphate buffered saline (PBS), other saline solutions, dextrose solutions, glycerol solutions, water emulsions and oils such as those made with oils of petroleum, animal, vegetable or synthetic origin (peanut oil, soybean oil, mineral oil or sesame oil). An artificial FCE can be used as a vehicle. The vehicle will preferably be sterile and pyrogen free. The concentration of the EMA or other lysosomal hydrolase enzyme in the pharmaceutical composition can vary widely, that is, from at least about 0.01% by weight, to 0.1% by weight, to about 1% by weight, at most 20% by weight or more of the total composition.

For intreventricular administration of EMA or other lysosomal hydrolase enzyme, the composition must be sterile and should be fluid. It should be stable under manufacturing and storage conditions and should be preserved against the contaminating action of microorganisms such as bacteria and fungi. The prevention of the action of microorganisms can be achieved by various antibacterial and antifungal agents, for example, parabens, chlorobutanol, phenol, ascorbic acid, thimerosal and the like. In many cases, it will be preferable to include isotonic agents, for example, sugars, polyalcohols such as mannitol or sorbitol, or sodium chloride in the composition.

The dosage of EMA or other lysosomal hydrolase enzyme may vary somewhat from individual to individual, depending on the particular enzyme and its specific in vivo activity, the route of administration, the medical condition, age, weight or sex of the patient, the sensitivities of the patient. to the EMA or other lysosomal hydrolase enzyme or vehicle components, and other factors that the doctor will be able to easily consider. Although the dosages may vary depending on the disease and the patient, the enzyme is generally administered to the patient in amounts of about 0.1 to about 1000 milligrams per 50 kg of patient per month. In one example, the enzyme is administered to the patient in amounts of about 1 to about 500 milligrams per 50 kg of patient per month. In other examples, the enzyme is administered to the patient in amounts of about 5 to about 300 milligrams per 50 kg of patient per month, or about 10 to about 200 milligrams per 50 kg of patient per month.

The rate of administration is such that the administration of a single dose can be administered as a bolus. A single dose can also be infused for approximately 1-5 minutes, approximately 5-10 minutes, approximately 10-30 minutes, approximately 30-60 minutes, approximately 1-4 hours, or consumes more than four, five, six, seven or eight hours. It can take more than 1 minute, more than 2 minutes, more than 5 minutes, more than 10 minutes, more than 20 minutes, more than 30 minutes, more than 1 hour, more than 2 hours or more than 3 hours. Applicants have noted that, although bolus intraventricular administration may be effective, slow infusion is very effective. Although applicants do not wish to be bound by any particular theory of operation, slow infusion is believed to be more effective due to a cerebrospinal fluid (FCE) renewal. Although estimates and calculations in the literature vary, it is believed that cerebrospinal fluid is renewed in approximately 4, 5, 6, 7 or 8 hours in humans. In one example, the slow infusion time should be measured so that it is approximately equal to or greater than the FCE renewal time. The renewal time may depend on the species, size and age of the subject but can be determined using methods known in the art. The infusion can also be continuous for a period of one or more days. The patient can be treated one, two or three or more times a month, eg, weekly, eg every two weeks. Infusions can be repeated during the course of a subject's life as dictated by the re-accumulation of the disease substrate in the brain or visceral organs. The re-accumulation can be determined by any of the techniques that are well known in the art for the identification and quantification of the relevant substrate, whose techniques can be performed on one or more samples taken from the brain and / or one or more of the visceral organs . Such techniques include enzymatic assays and / or immunoassays, eg, radioimmunoassays or ELISA.

The FCE empties into the blood through arachnoid villi and intracranial vascular sinuses, thus distributing the infused enzymes to the visceral organs that are known to be affected in the EDL. The visceral organs that are normally affected in Niemann-Pick disease are the lungs, spleen, kidney and liver. Slow intraventricular infusion provides decreased amounts of the substrate for an enzyme administered in at least the brain and potentially in the visceral organs. The reduction in the accumulated substrate in the brain, lungs, spleen, kidney and / or liver can be dramatic. Reductions of more than 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90% can be achieved. The reduction achieved is not necessarily uniform from patient to patient or even from organ to organ in a single patient. The reductions can be determined by any of the techniques that are well known in the art, eg, by enzymatic assays and / or immunoassay techniques, as discussed elsewhere in the present specification.

If desired, the structure of the human brain can be correlated with similar structures in the brain of another mammal. For example, most mammals, including humans and rodents, show a similar topographic organization of entorhinal-hippocampal projections, with neurons in the lateral part of both the lateral and medial entorhinal cortex that project to the dorsal or septal pole of the hippocampus, while the ventral hippocampal projection has its origin mainly in neurons in the middle parts of the entorhinal cortex (Principles of Neural Science, 4th ed., eds Kandel et al., McGraw-Hill, 1991; The Rat Nervous System, 2nd ed., ed. Paxinos, Academic Press, 1995). In addition, the layer II cells of the entorhinal cortex project to the dentate gyrus, and terminate in the outer two thirds of the molecular layer of the dentate gyrus. The axons of the layer III cells project bilaterally to the areas of the ammonium pole CA1 and CA3 of the hippocampus, ending in the molecular layer of the lacuninous layer.

In an illustrative example, administration is achieved by infusion of the EDL enzyme into one or both of the lateral ventricles of a subject or patient. Through infusion into the lateral ventricles, the enzyme is distributed to the site in the brain where the greatest amount of FCE is produced. The enzyme can also be infused into more than one ventricle of the brain. The treatment may consist of a single infusion per target site, or it may be repeated. Multiple infusion / injection sites can be used. For example, the ventricles in which the enzyme is administered may include the lateral ventricles and the fourth ventricle. In some examples, in addition to the first administration site, a composition containing the EDL enzyme is administered to another site that may be contralateral or ipsilateral to the first administration site. Injections / infusions can be single or multiple, unilateral or bilateral.

The distribution of the solution or other composition containing the enzyme specifically to a particular region of the central nervous system, such as to a particular ventricle, e.g., to the lateral ventricles or to the fourth ventricle of the brain, can be administered by stereotactic microinjection. . For example, on the day of surgery, patients will have the base of the stereotactic frame fixed at the site (screwed into the skull). The brain with the stereotactic framework base (compatible with the MRI with fiduciary marks) will be captured in images using high-resolution MRI. MRI images will then be transferred to a computer running a stereotactic program. A series of coronal, sagittal and axial images will be used to determine the injection site and vector trajectory. The program directly translates the trajectory into three-dimensional coordinates appropriate for the stereotactic framework. Drill holes are drilled above the entry site and the stereotactic apparatus located with the needle implanted at the given depth. The enzymatic solution in a pharmaceutically acceptable carrier will then be injected. Additional routes of administration may be used, eg superficial cortical application under direct visualization or other non-stereotactic application.

One way to distribute a slow infusion is to use a pump. Such pumps are commercially available, for example, from Alzet (Cupertino, CA) or Medtronic (Minneapolis, MN). The pump can be implantable. Another way convenient to administer enzymes is to use a cannula or catheter. The cannula or catheter can be used for multiple administrations separated in time. Cannulas and catheters can be stereotaxically implanted. It is contemplated that multiple administrations will be used to treat the typical patient with a lysosomal deposition disease. Catheters and pumps can be used separately or in combination.

Lysosomal deposition (EDL) diseases include more than forty genetic disorders, many of which involve genetic defects in several lysosomal hydrolases. Representative lysosomal deposition diseases and associated defective enzymes are listed in Table 1.

Gaucher disease results as a consequence of an inherited deficiency of the lysosomal glucocerebrosidase (GC) hydrolase, which leads to the accumulation of its substrate, glucosylceramide (GL-1), in histiocyte lysosomes. The progressive accumulation of GL-1 in tissue macrophages (Gaucher cells) occurs in several tissues. The extent of accumulation is partly dependent on the genotype. Clinically, three different Gaucher phenotypes are recognized, the non-neuropathic type 1, which is the most common with the onset that ranges from early childhood to maturity, and the neuropathic types 2 and 3, which occur in childhood and childhood early, respectively. Any of these phenotypes can be treated in accordance with the present description. The primary clinical manifestations common to all forms of Gaucher disease are hepatosplenomegaly, cytopenia, pathological bone fractures and, occasionally, pulmonary failure. A detailed discussion of Gaucher's disease can be found in the Online Metabolic & Molecular Bases of Inherited Diseases, Part 16, chapter 146 and 146.1 (2007). In patients with Gaucher disease type 2 and type 3 in which there is significant central nervous system involvement, intraventricular distribution of the defective EDL enzyme leads to improved metabolic state of the brain and potentially of the affected visceral organs (not of CNS) . Intraventricular distribution of the defective EDL enzyme in subjects with Gaucher disease type 1 leads to improved metabolic status of affected visceral organs (not CNS). There are animal models of Gaucher disease, which have been derived from mouse models created by directed disruption of the corresponding mouse gene. For example, there is a Gaucher mouse model that houses the D409V mutation in the mouse GC position (Xu, Y-H et al. (2003). Am. J. Pathol. 163: 2093-2101). The heterozygous mouse, g¿> aD409V / null, shows ~ 5% of normal GC activity in visceral tissues and develops swollen macrophages with lipids (Gaucher cells) in the liver, spleen, lung and bone marrow at 4 months of age. This model is an appropriate system in which to evaluate the benefits of and determine the conditions for intraventricular distribution of the defective EDL enzyme in subjects with Gaucher disease.

Niemann-Pick disease (ENP) is a lysosomal deposition disease and is a hereditary neurometabolic disorder characterized by a genetic deficiency in acid sphingomyelinase (EMA; sphingomyelin choline phosphohydrolase, EC 3.1.3.12). The lack of functional EMA protein results in the accumulation of sphingomyelin substrate in the lysosomes of neurons and glia throughout the brain. This leads to the formation of large numbers of distended lysosomes in the pericarion, which are a distinctive feature and the primary cellular phenotype of ENP type A. The presence of distended lysosomes correlates with the loss of normal cellular function and a progressive neurodegenerative course that leads at the death of the affected individual in early childhood (The Metabolic and Molecular Bases of Inherited Diseases, eds. Scriver et al., McGraw-Hill, New York, 2001, pp. 3589-3610). Secondary cell phenotypes (eg, additional metabolic abnormalities) are also associated with this disease, especially the high level of cholesterol accumulation in the lysosomal compartment. Sphingomyelin has a strong affinity for cholesterol, which results in the sequestration of large amounts of cholesterol in the lysosomes of ASMKO mice and human patients (Leventhal et al. (2001) J. Biol. Chem., 276: 44976-44983; Slotte (1997) Subcell. Biochem., 28: 277-293; and Viana et al. (1990) J. Med. Genet., 27: 499-504). A detailed discussion of ENP disease can be found in the Online Metabolic & Molecular Bases of Inherited Diseases, Part 16, Chapter 144 (2007). There are animal models of ENP. For example, ASMKO mice are an accepted model of Niemann-Pick disease types A and B (Horinouchi et al. (1995) Nat. Genetics, 10: 288-293; Jin et al. (2002) J. Clin. Invest ., 109: 1183-1191; and Otterbach (1995) Cell, 81: 1053-1061). Intraventricular distribution of the defective EDL enzyme leads to the improved metabolic state of the brain and the affected visceral organs (not CNS).

Mucopolysaccharidoses (MPS) are a group of lysosomal deposition disorders caused by enzyme deficiencies that catalyze the degradation of glycosaminoglycans (mucopolysaccharides). There are 11 known enzyme deficiencies that result in 7 different MPS, which include MPS I (Hurler, Scheie and Hurler-Scheie syndromes) and MPS II (Hunter syndrome). Any MPS can be treated in accordance with this description. A detailed discussion of MPS can be found in the Online Metabolic & Molecular Bases of Inherited Diseases, part 16, chapter 136 (2007). There are numerous animal models of MPS, which have been derived from mutations that occur naturally in dogs, cats, rats, mice and goats, in addition to mouse models created by directed disruption of the corresponding mouse gene. The biochemical and metabolic characteristics of these animal models are generally quite similar to those found in humans; however, clinical presentations may be softer. For example, the accepted models for MPS I include a murine model [Clark, LA et al., Hum. Mol. Genet (1997), 6: 503] and a canine model [Menon, KP et al., Genomics (1992), 14: 763]. For example, the accepted models for MPS II include a mouse model [Muenzer, J. et al., (2002), Acta Paediatr. Suppl .; 91 (439): 98-9]. In MPS that have involvement of the central nervous system, as found in patients with MPS I and MPS II, intraventricular distribution of the defective EDL enzyme leads to an improved metabolic state of the brain and potentially affected visceral organs (not CNS). .

Pompe disease, or type II glycogen deposition disease (EDGII), also called acid maltose deficiency (DMA) is an inherited disorder of glycogen metabolism that results from defects in the activity of acid lysosomal hydrolase alpha-glucosidase in all tissues of affected individuals. Enzymatic deficiency results in the intralisosomal accumulation of glycogen of normal structure in numerous tissues. The accumulation is more marked in the cardiac and skeletal muscle and in liver tissues of children with the generalized disorder. In late-onset EDGII, intralisosomal glycogen accumulation is virtually limited to skeletal muscle and is of lesser magnitude. Electromyographic abnormalities that suggest diagnosis include pseudomiotonic discharges and irritability, although in patients of juvenile and adult onset, abnormalities may vary in different muscles. CT scans can reveal the site (s) of affected muscles. Most patients have elevated blood plasma levels of creatine kinase (CK) and elevations in liver enzymes can be found, particularly in start-up patients in adults. There are several animal models that occur naturally from childhood and late onset disease. There is a mouse model with deactivated gene [Bijvoet AG et al., Hum. Mol. Genet (1998); 7: 53-62]. Enhancing effects of enzyme therapy have been described in mice with deactivated gene [Raben, N et al., Mol. Genet Metab (2003); 80: 159-69] and in a quail model. Intraventricular distribution of the defective EDL enzyme leads to the improved metabolic state of the brain and potentially the affected visceral organs (not CNS).

Zeroide neuronal lipofuscinosis (CNL) is a group of neurodegenerative disorders distinguished from other neurodegenerative diseases by the accumulation of autofluorescent material ("aging pigment") in the brain and other tissues. The main clinical features include, epileptic seizures, psychomotor impairment, blindness and premature death. Different subgroups of LNC have been recognized that differ in the age of onset of symptoms and the appearance of deposit material by electron microscopy. Three main groups - childhood (LNCI), late childhood classic (LNCIT) and juvenile (LNCJ, also called Batten disease) - are caused by autosomal recessive mutations in the CLN1, CLN2 and CLN3 genes, respectively. The protein products of the CLN1 (palmitoyl-thioesterane protein) and CLN2 (tripeptidyl peptidase or pepinase) genes are soluble lysosomal enzymes, while the CLN3 (battenin) protein is a lysosomal membrane protein, as is (provisionally) the CLN5 protein . The identification of mutations in genes encoding lysosomal proteins in various forms of LNC has led to the recognition of lipofuscinosis as real lysosomal deposition disorders. Any subgroup of LNC can be treated in accordance with this description. A detailed discussion of LNC disease can be found in the Online Metabolic & Molecular Bases of Inherited Diseases, part 16, chapter 154 (2007). Naturally occurring CNL disorders have been described in sheep, dog and mouse models have been derived by directed disruption of a corresponding mouse gene [see eg, Katz, ML et al., J. Neurosci. Res. (1999); 57: 551-6; Cho, SK et al., Glycobiology (2005); 15,637-48]. Intraventricular distribution of the defective EDL enzyme leads to the improved metabolic state of the brain and possibly the affected visceral organs (not CNS).

A detailed discussion of additional lysosomal deposition disorders described in Table 1, in which the intraventricular distribution of the defective EDL enzyme in the disease can be found in the Online Metabolic & Molecular Bases of Inherited Diseases, part 16 (2007).

A general description of the present description is given above.

A more complete understanding can be obtained by reference to the following specific examples provided herein for purposes of illustration only, and are not intended to limit the scope of the invention.

Example 1

Animal model

ASMKO mice are an accepted model of Niemann-Pick disease types A and B (Horinouchi et al. (1995) Nat. Genetics, 10: 288-293; Jin et al. (2002) J. Clin. Invest., 109 : 1183-1191; and Otterbach (1995) Cell, 81: 1053-1061). Niemann-Pick disease (ENP) is classified as a disease by lysosomal deposition and is an inherited neurometabolic disorder characterized by a genetic deficiency in acid sphingomyelinase (EMA; sphingomyelin choline phosphohydrolase, EC 3.1.3.12). The lack of functional EMA protein results in the accumulation of sphingomyelin substrate in the lysosomes of neurons and glia throughout the brain. This leads to the formation of large numbers of distended lysosomes in the pericarion, which are a distinctive feature and the primary cellular phenotype of ENP type A. The presence of distended lysosomes correlates with the loss of normal cellular function and a progressive neurodegenerative course that leads to the death of the affected individual in early childhood (The Metabolic and Molecular Bases of Inherited Diseases, eds. Scriver et al., McGraw-Hill, New York, 2001, pp. 3589-3610). Secondary cell phenotypes (eg, additional metabolic abnormalities) are also associated with this disease, especially the high level of cholesterol accumulation in the lysosomal compartment. Sphingomyelin has a strong affinity for cholesterol, which results in the sequestration of large amounts of cholesterol in the lysosomes of ASMKO mice and human patients (Leventhal et al., (2001) J. Biol. Chem., 276: 44976-44983 ; Slotte (1997) Subcell. Biochem., 28: 277-293; and Viana et al., (1990) J. Med. Genet., 27: 499-504).

Example 2

"Continuous intraventricular infusion of EMAhr in the ASMKO mouse".

Objective: to determine what effect the intraventricular infusion of recombinant human EMA (EMAhr) has on pathology by deposition (i.e., deposition of sphingomyelin and cholesterol) in the ASMKO mouse brain.

Methods: ASMKO mice were stereotaxically implanted with an internal guide cannula between weeks 12 and 13 of age. At 14 weeks of age, mice were infused with 250 mg of EMAh (n = 5) for a period of 24 h (~, 01 mg / h) for four consecutive days (1 mg total was administered) using a Infusion probe (fits inside the guide cannula) that is connected to a pump. Freeze-dried EMAh was dissolved in artificial cerebrospinal fluid (FCEa) before infusion. Mice were sacrificed 3 days after infusion. For sacrifice, an overdose was applied to the mice with eutasol (> 150 mg / kg) and then perfused with PBS or 4% parformaldehyde. The brain, liver, lung and spleen were removed and analyzed for sphingomyelin (MS) levels. The brain tissue was divided into 5 sections before the MS analysis (S1 = front part of the brain, S5 = back part of the brain; see Fig. 1).

Table 2

Summary of results: Intraventricular infusion of EMAh at 250 mg / 24 h for 4 continuous days (1 mg total) resulted in EMAh staining and clearance of filipin (i.e. cholesterol deposition) through the ASMKO brain. The biochemical analysis showed that the intraventricular infusion of EMAh also led to a global reduction in EM levels through the brain. MS levels were reduced to wild-type (TS) levels. A significant reduction in MS was also observed in the liver and spleen (a downward trend was seen in the lung).

Example 3

"Intraventricular distribution of EMAh in ASMKO II mice"

Objective: to determine the lowest effective dose during an infusion period of 6 h.

Methods: ASMKO mice were stereotaxically implanted with an internal guide cannula between weeks 12 and 13 of age. At 14 weeks of age, mice were infused for a period of 6 hours at one of the following doses of EMAh: 10 mg / kg (, 250 mg; n = 12), 3 mg / kg (, 075 mg; n = 7), 1 mg / kg (, 025 mg; n = 7),, 3 mg / kg (, 0075 mg; n = 7) or FCEa (artificial cerebrospinal fluid; n = 7). Two mice of each dose level were perfused with 4% parformaldehyde immediately after the 6 h infusion to assess the enzymatic distribution in the brain (blood was then collected from them to determine serum EMAh levels) . The remaining mice in each group were sacrificed 1 week after infusion. The brain, liver and lung tissue of these mice was analyzed for MS levels as in study 05-0208.

Table 3

Summary of results: Intraventricular EMAh over a period of 6 h led to a significant reduction in EM levels across the brain despite the dose. Cerebral MS levels in mice treated with doses> 0.025 mg were reduced to TS levels. The MS levels of the visceral organs were also significantly reduced (but not to TS levels) in a dose-dependent manner. In support of this discovery, the EMAh protein was also detected in the serum of ASMKO mice infused with EMAh protein. Histological analysis showed that the EMAh protein was widely distributed throughout the brain (from S1 to S5) after intraventricular administration of EMAh.

Example 4

"Intraventricular Infusion of EMAhr in ASMKO III Mice"

Objective: to determine (1) the time it takes for MS to accumulate again in the brain (and spinal cord) after 6 h of EMAh infusion (dose = 0.025 mg); (2) if there are differences by sex in response to the administration of intraventricular EMAh (previous experiments show that there are differences by sex in the accumulation of substrate in the liver, whether or not this occurs in the brain is unknown).

Methods: ASMKO mice were stereotaxically implanted with an internal guide cannula between weeks 12 and 13 of age. At 14 weeks of age the mice were infused for a period of 6 h with 0.025 mg of EMAh. After intraventricular distribution of EMAh, mice were sacrificed either 1 week after infusion (n = 7 males, 7 females), or 2 weeks after infusion (n = 7 males, 7 females) or at 3 weeks after infusion (n = 7 males, 7 females). In the sacrifice, the brain, spinal cord, liver and lung were removed for MS analysis.

Table 4

Tissue samples are prepared for MS analysis.

Example 5

"Effect of EMAhr intraventricular infusion on cognitive function in ASMKO mice"

Objective: to determine if the intraventricular infusion of EMAhr relieves the induced cognitive deficits in patients in ASMKO mice.

Methods: ASMKO mice are stereotaxically implanted with an internal guide cannula between weeks 9 and 10 of age. At 13 weeks of age, mice are infused for a period of 6 h with 0.025 mg of EMAh. At 14 and 16 weeks of age, mice undergo cognitive tests using the Barnes labyrinth.

Example 6

"The distribution of EMAh protein in the ASMKO CNS after intraventricular infusion"

Objective: to determine the distribution of EMAh protein (as a function of time) in the brain and spinal cord of ASMKO mice after intraventricular infusion.

Methods: ASMKO mice are stereotaxically implanted with an internal guide cannula between weeks 12 and 13 of age. At 14 weeks of age, mice are infused for a period of 6 h with 0.025 mg of EMAh. After the infusion procedure, the mice are sacrificed either immediately or 1 week or 2 weeks or 3 weeks later.

Table 5. Indicates the infusion times that can be used with a particular enzyme for the treatment of the disease in which it is deficient as indicated in Table 1.

References

1) Belichenko PV, Dickson PI, Passage M, Jungles S, Mobley WC, Kakkis ED. Penetration, diffusion, and uptake of recombinant human alpha-l-iduronidase after intraventricular injection into the rat brain. Mol Genet Metab. 2005; 86 (1-2): 141-9.

2) Kakkis E, McEntee M, Vogler C, Le S, Levy B, Belichenko P, Mobley W, Dickson P, Hanson S, Passage M. Intrathecal enzyme replacement therapy reduces lysosomal storage in the brain and meninges of the canine model of MPS I. Mol Genet Metab. 2004; 83 (1-2): 163-74.

Claims (5)

1. An acid sphingomyelinase for use in the prevention or treatment of Niemann-Pick A or B disease in a patient, wherein said prevention or treatment comprises intraventricular administration of acid sphingomyelinase to the patient's brain, in which the administration of a single dose of acid sphingomyelinase consumes more than five hours. 2. The acid sphingomyelinase for use according to claim 1, wherein said prevention or treatment comprises the administration of acid sphingomyelinase to the lateral ventricles and / or to the fourth ventricle of the brain. 3. The acid sphingomyelinase for use according to claim 1 or claim 2, wherein said prevention or treatment comprises determining the re-accumulation of sphingomyelin in the brain and / or in one or more visceral organs. 4. The acid sphingomyelinase for use according to any one of claims 1 to 3, wherein the acid sphingomyelinase is to be administered using a pump and / or a catheter. 5. The acid sphingomyelinase for use according to any one of claims 1 to 4, wherein the administration comprises a plurality of infusions of acid sphingomyelinase.